S In What Way Can Primary Care Contribute to Reducing Health Inequalities?

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ocial inequalities in health are to be found in all European countries (Mackenbach et al., 2008; van Dooslaer et al., 2004).

Following a report from the World Health Organisation Commission on Social Determinants of Health (WHO, 2008), health inequalities were reco- gnised as a major public health issue.

Reducing these inequalities has thus become a stated political objective in numerous European countries (Jusot,

2010) including France where the issue became part of the political agenda following a report published by the French High Council for Public Health (HCSP, 2009).

The implementation of such a policy entails defining possible entry points.

Two European projects, DETERMINE (Needle, 2008) and EUROTHINE (Erasmus, 2008), analysed efforts to tackle the social determinants of health

inequalities and recommended imple- menting policies aimed at improving working conditions, access to edu- cation, housing and more generally, reducing income inequality (Bambra et al., 2010). The European project AIR (Addressing Inequalities Interventions in Regions) suggests studying the pos- sibility of reducing health inequalities by means of policies and action plans directly affecting healthcare organisation, and more

In What Way Can Primary Care

Contribute to Reducing Health Inequalities?

A Review of Research Literature

Yann Bourgueil (Irdes ; Prospere), Florence Jusot (Université de Rouen ; Irdes ; Leda-Legos), Henri Leleu (Irdes) and the AIR Project Group

After defining primary healthcare and explaining its role as an organisational prin- cipal in an integrated health system in reducing social inequalities in health, we present a review of current research literature with a focus on effective initiatives in this domain. This review was carried out within the framework of the European project AIR (Addressing Inequalities Interventions in Regions). Three areas of intervention in the primary care sector were distinguished. The first concerns the development of disease prevention programmes, the second, measures aimed at improving specific populations’ financial access to healthcare, and the third, the introduction of best practice protocols aimed at improving the quality of care for the population as a whole within a framework of health system reorganisation.

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care. In the same way, they can also encourage compliance with treatments and prescriptions and help patients in learning to live with a disease. Health literacy is acquired and transmitted both through durable and repeated interpersonal relationships (between patients, between patients and health professionals), and mass communica- tions (information campaigns). The ambulatory or primary care system, being in closer contact with patients from all social categories, promotes the development of interpersonal rela- tionships and thus in theory contri- butes to reducing health inequalities.

Reducing health inequalities using primary care as a health system

organisational principle

The way in which primary care contri- butes to reducing health inequalities can be understood from the systemic approach of health system organisatio- nal principles.

Comparative studies have revealed inequalities in healthcare consump- tion in all European health systems (for example, Bago d’Uva and Jones, 2009; Or et al., 2009; Jusot et al., 2012;

Devaux and de Looper, 2012). These inequalities are significant for specialist care, dental and optical care and pre- ventive care whereas the utilisation rate for general practitioners is more equi- tably distributed.

However, the social inequalities in the use of healthcare services are lower in countries with a national health system, where patients’ out-of-pocket payments are limited and where general practitio- ners play the role of gatekeeper* (Bago d’Uva and Jones, 2009; Or et al., 2009).

Furthermore, social health inequalities are systematically reduced in countries with a high level of state intervention in the health and social domains (Dahl et al., 2006; Eikemo et al., 2008).

L’Aide pour une complémentaire santé (ACS) is a French scheme instituted in 2005 to help households whose income levels fall just above the eligibility thresh- old for Universal Complementary Health Insurance (CMU-C) acquire complemen- tary health insurance.

Disease management, or Programme spécifique de prise en charge des ma- ladies chroniques, aims at encouraging patients to better manage their illness by offering a specific support programme in conformity with medical recommenda- tions and the protocol in force

Gatekeeping refers to the coordination of care by the general practitioner who controls access to secondary care (spe- cialists and hospital care…)..

Managed care, or soins intégrés, re- fers to a networked organisation of care aimed at rationalising disease manage- ment and better cost control. Managed

care coordinates care between private practice and the hospital.

Pay for Performance, or Paiement à la performance par objectif de santé pu- blique, is based on financial incentives for general practitioners who respect public health objectives by means of a list of ‘good practice’ indicators.

Quality Outcome Framework (QOF) is a Pay for Performance programme intro- duced in the United Kingdom in 2004 aimed at general practitioners and group practices. It is based on a list of indicators concerning clinical and organisational quality and patient satisfaction.

A safety net hospital in the United States provides free healthcare to individuals that otherwise have difficulty access- ing care due to either difficult financial situations, , the lack health insurance, or health status.

G ^LOSSARY

or in other words the services ensured by professionals in the ambulatory care sector. As a rule, general practitioners play a prominent role even if the idea of interprofessional teams associating other medical and social care profes- sionals appear better suited in dealing with the complexity of situations cur- rently encountered within the ambula- tory care sector (WHO 2008).

The interest of intervening from within the health system to reduce social health inequalities has already been underlined (Couffinhal et al., 2005).

In theory, if the population has regu- lar contact with its general practitio- ner, relying on the latter and/or the first contact care team appears to be a means of ensuring universal access to health care and, in broader terms, of globally enhancing patients’ self health management. Achieving the latter sup- poses assisting patients in reducing health risk behaviours in favour of pre- ventive health behaviours. In the event of illness, professionals in the primary care sector seem to be in the best posi- tion to facilitate patients’ efficient use of the health system, notably secondary particularly the primary care sector.

A review of current research literature was carried out within the framework of this project in order to identify the different interventions in this sector having proved their effectiveness in reducing inequalities in health, health care consumption or health-related behaviours. After a brief reminder of the key arguments put forward to jus- tify implementing measures within the primary care sector to reduce health inequalities, we present the conclusions of the literature review.

Primary care:

definition and theory

Since its definition at the Alma-Ata conference in 1978, the concept of primary care has become a vehicle for social justice aimed at guaranteeing access to basic medical care for all. In its operational context, the concept of primary care invokes the notion of first contact, accessibility, continuity, permanence and the coordination of care in connection with other sectors,

* The words or terms followed by an asterisk are de- fined in the glossary p.2.

as they are more equitable in terms of access to healthcare and more cost- effective (Macinko et al., 2003).

Without going as far as organising the health system around primary care, isolated interventions within the sec- tor can also be envisaged to reduce health inequalities. The aim of the literature review carried out within the framework of the AIR project was to identify the actions and practices implemented in the primary care sector whose impact on the health outcomes of different socioeconomic groups had been monitored.

Primary care: a target sector for effective interventions to reduce health inequalities

The review of research literature, the key results of which are presented here, aimed at identifying articles eva-

luating the impact of interventions in primary care on health status, healthcare consumption or health risk behaviours by socioeconomic group or specific disadvantaged groups, published between January 2000 and February 2010 (Methods insert). Ninety eight interventions resulting in an isolated publication and ten literature reviews were retai- ned. The majority of these interven- tions were carried out in the United States (80  %), the remainder in the United Kingdom, the Netherlands, New Zealand, Australia, France and Hungary.

Interventions having proved their effectiveness in reducing socioecono- mic health inequalities were classi- fied by domain and type of ‘action’

(see opposite) resulting in three sepa- rate groupings: interventions aimed at improving financial access to care either through the introduction of free healthcare or free or subsidized health insurance, interventions pro- moting community healthcare and interventions concerning healthcare organization.

Health insurance covering the totality of healthcare costs

increases and improves healthcare utilisation and improves

health status among the poorest populations

The policies and measures implemen- ted in an attempt to improve finan- cial access to care can be divided into two types of action: on the one hand, attempts to improve health insurance coverage and on the other, the provi- sion of free healthcare. The first not only includes improving specific popu- lation categories’ health insurance coverage through the provision of free or subsidised complementary health insurance, but also by reducing patient contributions or simplifying appli- cation procedures for entitlement to public insurance. The provision of free healthcare includes free screening and vaccination programmes, free dental Furthermore, an analysis of policies

aimed at reducing health inequali- ties in Europe first of all reveal that the European countries whose health systems are structured around the principle of primary care such as the United Kingdom, the Netherlands and Sweden, were the first to imple- ment real strategies aimed at redu- cing social health inequalities (Jusot, 2010). Beyond isolated interventions, it thus appears that the organisatio- nal principle based on an integrated, managed care system leads to the emer- gence of coordinated public policies with the stated objective of fighting against inequalities which, according to Whitehead (2008), is the only way to achieve the objective. Comparative stu- dies have thus shown that health sys- tems based on ‘strong’ primary health care systems such as Australia, Canada, Japan, Sweden, Denmark, Finland, the Netherlands, Spain, and the United Kingdom are on average more effective in improving populations’ health than those with ‘weak’ primary care systems

Classification of the interventions identified in the literature review

Area of

intervention Type of intervention Examples

  

Financial access to care

Free or subsidised complementary health

- Universal Complementary Health Insurance (CMU-C) - Financial assistance in acquiring complemntary health

insurance - Aide pour une complémentaire santé (ACS)

Free healthcare

- Screening for breast and colorectal cancers…

- Vaccination

- Mother-child preventive care (Maternal and infantile protection (PMI))

Targeted preventive actions

Information adapted to populations

- Multilingual documents

- Bilingual professional and non-professional educators

Actions

aimed at changing behaviours

- Prevention of HIV transmission, nicotine addiction, nutrition…

Health system organisation

Not-specificically aimed at health inequalities

- Disease management programmes:

heart failure and diabetes - Case management programmes - Goal-based Pay for Performance schemes

Oriented towards categories of underpriviledged populations

- Interventions targeting: child care

- Screening and care delivery by dedicated health teams (general practitioners, nurses, social workers...)

Intervention framework

Overall contractual framework aimed at financing tailor-made interventions initiated and developed by local players to reduce health inequalities

care and access to safety net hospitals*.

In this category, actions are generally focused on the poorest population cate- gories and are implemented globally at health system level and often over the long term.

The literature clearly establishes that providing complementary insurance covering the totality of health costs for populations not previously covered increases their use of healthcare ser- vices. Several studies have also revealed an improved health outcome particu- larly among the poorest populations and children. These conclusions were notably established from modifications to the eligibility criteria for Medicaid in the United States (Currie et al., 2008) or the creation of the CMU in France (Grignon et al., 2008). They are also comparable to the results of two major experiments carried out in the United States: the experiments carried out by the RAND in the 1970’s (Newhouse, 1993) or more recently in Oregon (Finkelstein et al., 2011).

However, improving the theoretical access to healthcare does not suffice to eradicate inequalities in health and healthcare consumption. Several stu- dies have revealed a tendency to under- utilise all schemes aimed at providing free or subsidised insurance coverage.

The partial subsidising of complemen- tary health insurance premiums for the poorest populations is globally ineffec- tive. The residual premium borne by the insured, even minimal, remains an obstacle to insurance subscriptions for lower income groups. The low uti- lisation rate for the ACS* scheme in France is one example (Guthmuller et al., 2011) that is consistent with the results of several studies carried out in the United States (Auerbach & Ohri, 2006; Thomas,  2010; Marquis &

Long, 1995). We also observe a non-uti- lisation rate for schemes aimed at pro- viding free insurance coverage for the poorest populations, such as Medicaid in the United States (Currie, 2006) and the Universal Complementary Health Insurance (CMU-C) in France (Dufour-Kippelen et al., 2006). In this case, the non-utilisation rate can be explained by poor knowledge of the eli-

gibility criteria, the complexity of appli- cation procedures or the fear stigmati- sation associated with social assistance (Currie, 2006). Help with subscrip- tion procedures in a one-to-one situa- tion could then be an efficient means of partially overcoming these barriers (Niescierenko, 2006).

Furthermore, differences in the quality of care between free and paid care have been observed (Bradley, 2008). Patients benefitting from free complementary health insurance can thus be confron- ted with the refusal of care (Currie, 200; Després, 2010) in cases where the scheme generates a lower remuneration rate for the physician.

Numerous preventive health interventions whose effectiveness

among vulnerable populations has been demonstrated

Preventive health interventions, pre- dominant in the literature review, aim to act on behaviours and lifestyles that contribute to reinforcing health ine- qualities. They notably include prima- ry and secondary prevention and health education. The WHO defines prima- ry prevention as all activities aimed at reducing the risk of new cases by edu- cating and informing the population.

Secondary prevention refers to all acti- vities aimed at detecting disease in its earliest stages.

In terms of primary prevention, the initiatives and practices identified in the review of the literature tend on the whole to be focused on nutrition: pre- vention of obesity (Resnicow K. et al., 2000; Hollar D. et al.,  2010), impro- ving the nutrition of children (Hoynes H.W. et al., 2009; Ilett & Freeman, 2004) and adults (Havas et al., 2003;

Birmingham et al., 2004) and pre- venting diabetes (Nine et al., 2003;

Auslander et al., 2002). Other actions focus on several objectives  : the fight against HIV transmission (DeMarco et al., 2009; Dancy et al., 2000), the fight against nicotine addiction (Guilamo- Ramos et al.,  2010; Wadland et al.,

2001) and the use of drugs (Wechsberg et al., 2007), the prevention of cardio- vascular disease (El Fakiri et al., 2008), the promotion of vaccines (Schensul, 2009) particularly against hepati- tis B (Deuson et al.,  2001; Chang et al.,  2009), and the improvement of psychological well-being (Barnet et al.,  2007  ; Schutgens et al.,  2009).

Secondary prevention essentially involves screening for cardiovascular diseases (Horgan et al.,  2010), dia- betes (Porterfield et al., 2004; Goyder et al.,  2008) and cancers, notably colorectal, breast and cervical cancers (Blumenthal et al.,  2005; Gourin et al., 2009).

The majority of actions and policies implemented within the framework of health prevention address economically disadvantaged populations and specific population groups. The literature sug- gests the need to provide both cultu- rally and linguistically adapted infor- mation (Black et al.,  2000; Arblaster et al.,  1996). One of the difficulties encountered in preventive practices is the ability to deliver information adapted to different social groups.

The impact of information campaigns aimed at reducing cultural barriers have been evaluated and show that face- to-face interventions are preferable to mass information campaigns (Spadea et al., 2010). These are generally carried out by either health educators or bilin-

C ^ONTEXT

This literature review was carried out within the framework of the European project AIR (Addressing Health Inequalities Interventions in Regions). The ultimate aim of this project, made up of several teams each representating a region in a partner European country, is to identify actions undertaken in the health sector to reduce social health inequalities at regional level on the one hand, and on the other to evaluate their effectiveness. Within the framework of this project, IRDES was charged with carrying out a review of current research literature on interventions aimed at reducing health inequalities in the primary care sector that had been subject to an evaluation, the results of which were subsequently published.

For further information:

http://www.air.healthinequalities.eu/

http://www.air.healthinequalities.eu/sites/default/

files/AIR%20Project%20WP4%20report.pdf

M ^ÉTHOD

The review of the literature evaluating the impact of interventions carried out in the primary care sector on health status, healthcare consumption or health risk beha- viours was carried out by selecting articles published between January 2000 and February 2010 using various databases: MEDLINE, the NBER database, the Cochrane review and Health Policy Monitor databases, and the Eurothine project report.

National databases such as the BDSP and Cindoc were consulted in France, the Netherlands, Belgium and Italy. A first selection was conducted using a key-word search based on MESH terminology aimed at identifying articles concerning primary care, health inequalities and evaluations.

The key words related to healthcare services in the primary care sector, included the promotion of health, access to the diagnosis and treatment of common illnesses, maternal and infantile care and also organisational characteristics such as first contact care, coordinated and integrated patient-centred care over the long term and health professional payment methods. Key words related to health inequalities included terms relating to differences, inequalities, iniquity and the social deter- minants of health. Finally, key words relating to evaluation took into account both specific programme evaluations and interventional studies.

At the end of the first phase, a second selection based on the titles and abstracts of articles from the first selection was carried out. Only articles describing an interven- tion in the primary care sector aimed at reducing health inequalities implemented in a developed country were retained or those where the impact on health or health behaviours among specific population categories had been evaluated.

Of the 1,044 articles identified on Medline, 89 were retained. 6 articles were identified in the Cochrane Journals, 4 in the Health Policy Monitor database, 2 in the Eurothine rapport and 7 in the NBER database. In total, 108 articles were analysed of 98 concerned isolated interventions and 10 reviews of literature on different interventions.

gual health professionals (nurses, edu- cators, clinicians). Sometimes telephone follow-ups or regular visits are neces- sary. Individual accompaniment and community social work also appear to contribute to the success of this type of action. Nevertheless, setting-up cultu- rally adapted communications is dif- ficult and implies a large number of small-scale, tailor-made interventions as suggested in the WHO Commission for the Social Determinants of Health report. Several articles suggest that the creation of a legal and/or financial framework (framework intervention) could facilitate the setting-up of a large number of local, tailor-made interven- tions (Wendel-Vos et al., 2009; Or et al., 2009; McKinney et al., 2002), such as the urban health workshops in France.

The literature also underlines that ini- tiatives should first and foremost tar- get diseases that contribute the most to creating health inequalities, such as cardiovascular diseases that repre- sent half the excess mortality between the lower and upper social classes in Europe (Mackenbach, 2008). In this

respect, prevention against nicotine addiction and dietary education are priority action areas.

Finally, the role played by primary care physicians in preventive health is not clearly defined in the litera- ture. Even if minimal inequalities in the access to general practitioners are observed in Europe placing them in a favourable position to play a key role in preventive health, the majority of interventions in this domain have been implemented within the community framework rather than within health- care structures.

Measures aimed at improving the quality of health among the general population, through the organisation of health

care, contributes to reducing health inequalities

The initiatives and measures that contribute to improving the quality

of care notably include changes to the organisation of care such as the intro- duction of disease management* pro- grammes for the care of chronic diseases and managed care* programmes pro- moting team work, and financial mea- sures such as the Pay for Performance*

scheme. These measures generally fall within broader ranging health sys- tem reforms and were not specifical- ly implemented in view of reducing health inequalities. They are therefore not oriented towards a specific popu- lation category such as immigrant or low-income population categories, but towards the general population. Some of these measures have nevertheless been evaluated from the viewpoint of reducing health inequalities.

The literature review thus shows that cooperation between health profes- sionals and disease management pro- grammes oriented towards underpri- vileged populations can be effective in reducing health inequalities. For example, working in collaboration with a specialised nurse contributed to redu- cing the symptoms of depression in a low-income population group (Arean et al., 2005). Similarly, disease manage- ment programmes focused on heart fai- lure (Walker et al., 2004) and diabetes (Coberley et al., 2007) respectively improved symptoms and the quality of care among immigrant populations.

Similarly, one could rightly suppose that the Pay for Performance scheme, offering financial incentives in the aim of improving the quality of care, would incite physicians to devote more time to vulnerable population groups. However, an evaluation of the Quality Outcome Framework (QOF)*, the British Pay for Performance ini- tiative, gives contradictory results (Dixon, Khachatryan, 2010). If the QOF appears to have reduced social disparities for blood pressure indicators (Ashworth, 2008), it seems to have had little impact on the diabetes indicators (Millett et al., 2007). Furthermore, as underlined by a recent review, QOF evaluations from the point of equi- ty are rare and are undermined by numerous methodological limitations (Boeckxstaens et al., 2011).

The capitated payment system applied in managed care programmes has not specifically improved the quality of care for vulnerable populations (Currie and Fahr, 2005; Kaestner et al., 2002).

Similarly, initiatives specifically aimed at reducing health inequalities, often in the form of new services supplied in underprivileged areas (often small-scale experimental initiatives) have not deli- vered the results expected apart from an initiative designed to improve the quali- ty of services supporting the cessation of tobacco use within the Afro-American population (Fisher et al., 2004).

Overall, and despite its limitations, (cf. Limitations insert), this analysis of the literature thus underlines the important role played by the primary care sector in the reduction of socioe- conomic health inequalities through improved financial access to care, tar- geted preventive actions within the community or, to a lesser degree, cer- tain practices designed to improve the organisation of care.

What lessons to be drawn in the French context?

In France, primary care, defined as first contact care, does not structure health policy to the same extent as it does in the United Kingdom or Scandinavian countries.

Policies intended to address the concerns and tensions related to the outlook for available human resources in the health sector and an ageing population have been essentially sectorial (emergency services, disese-specific networks, pro- grammes concerning specific health issues such as the Mental Health Plan, the National Nutrition and Health Programme, the medical demographics plan, the Cancer Plan…). All the recent reforms in France (the Preferred Doctor scheme, the creation of Regional Health Agencies (ARS) in 2004, Regional Strategic Ambulatory Health Plans

(Sros), support for community organi- sation such as health centres, the intro- duction of the Pay for Performance scheme with the Contract to Improve Individual Practices (CAPI) indicate a growing interest for a better organi- zation of ambulatory care. However, beyond the accumulation of local and sectorial measures and actions imple- mented in France, is the question of developing a more integrated approach to healthcare organisation with greater constraints for the health professionals and patients in the organisation of care pathways between different levels of care (cf. conclusion Hcaam¹ advice, ses- sion of 22nd March 2012).

It is also in this context that the wil- lingness to define a policy intended to reduce health inequalities emerges, a policy that would reach beyond equal access to healthcare defended by the Hospital, Patients, Health and Territories Act (HPST). In effect, the 2009-2013 cancer plan places the aim to reduce social health inequalities in a cross-cutting context. France thus combines the political will to reduce health inequalities and the organisation

1 ‘Envisaging a health insurance at the service of public health policy based on a coordinated health- care circuit will no doubt be impossible without first questioning the current balance between both doctors and patients freedoms and constraints within the healthcare system. This should, how- ever, allow linking the future of the National Health Insurance to a project that continues to respect its founding principles.’

of primary care in one and the same movement.

Policies aimed at reducing health ine- qualities via the primary care sector can thus be implemented on the basis of two different options that do not exclude each other. The first consists in taking the numerous possibilities offered by isolated actions and diverse interventions addressing targeted popu- lations in cooperation with health sys- tem players rather than through them.

The literature review shows that they are effective in the fight against health inequalities wherever they are imple- mented. In France, the Urban Health Workshops and the future local health contracts can be likened to this type of intervention. The second more structu- ral option would be based on a reform of the French health system focused on primary care by adapting payment methods for GPs and other private prac- titioners or even by providing free pri- mary care for a wider population than that currently entitled to the CMU-C.

Whatever the measures adopted in the primary care domain, an evaluation of their impacts on health inequalities at pre and post implementation stages seems necessary. The very low num- ber of French publications on the sub- ject shows that it consists in a major challenge for researchers in the health

domain.

Limitations

This literature review has certain limitations. Firstly, the choice of only including evaluated measures and initiatives restricts the review to a partial representation as the vast majority of initiatives are not systematically evaluated. Also, not all evaluations are published due to weak results. The efficiency rate for evaluated actions, estimated at over 70% in the present review, probably indicates a methodological bias.

Secondly, the preponderance of Anglo-Saxon research, for the most part American, presents the risk of limiting the possibilty of transposing results onto other countries with very diffe- rent health system organisations. Initiatives specifically directed at ‘minority’ groups and insufficient access to health insurance is specific to the United States. In Europe, immigrant populations or communities are not always targeted as such and financial access to care is sometimes totally free of charge, notably in national health systems. Health system orga- nization at ‘macro’ level clearly appears to have an impact on health inequalities and the strategies to be adopted. Finally, the considerable heterogeneity of the articles selected renders a more complex analysis, identifying key success or efficiency factors for each type of action in the primary care sector, impossible.

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URTHER INFORMATION

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